LinkGiffords has "a long, difficult road" ahead, Philly-area experts sayBy Stacey Burling
Inquirer Staff Writer
Rep. Gabrielle Giffords likely will survive the gunshot that sent a bullet through the left side of her brain, but she faces months of difficult rehabilitation and probably will always have mental and physical impairments, local neurosurgeons and rehabilitation specialists say.
It's impossible to predict how severe her disabilities may be. The precise path of the bullet has not been made public. But even that information would not be enough. Each brain is different, and each person has a different capacity to heal that is affected by age, genetics, and other physical problems.
"I've had patients with very severe gunshot wounds who've done well," said Thomas Watanabe, clinical director of the Drucker Brain Injury Center at MossRehab, "and I have to say there are some who did not.
"I have to remind myself that every recovery path will be somewhat different."
Don McMullin, a former Philadelphia police officer who now works as a physical therapist for ManorCare in West Deptford, is living proof that people can thrive after a shot to the brain. He was 23 when he was shot during a traffic stop. The bullet went through his right eye socket and lodged in the back of his brain.
Two days later, a doctor told his twin brother, Brian, who had been on patrol with him, that it was time to say goodbye.
Since then, though, McMullin has changed careers, married a nurse, and fathered three children. Now 43, he is blind in his right eye and has limited peripheral vision with his left, but has no other physical problems. His short-term memory isn't great and he has trouble organizing things, especially when tired.
At Magee Rehabilitation, he learned how to compensate for his disabilities. He has to turn his head and eyes constantly, for example, to see around him. Eventually, that became second nature.
"The body, the spirit, tends to get used to the whole new way of doing things," he said.
Experts said Giffords (D., Ariz.) likely will face more severe challenges. Her injury traverses the left side of her brain, which, for those who are right handed, is the dominant side.
"It's in her dominant hemisphere. That's not good," said Christopher Loftus, chair of neurosurgery at Temple University School of Medicine. "It's going to be a long, difficult road."
The left side of the brain controls our ability to communicate - both to understand language and to generate it. It also controls movement in the right side of the body. Patients with this kind of injury could have right-side weakness or paralysis.
The purpose of surgery in a case like this is not to repair damage. The brain can't be repaired. The goal is to prevent complications such as infection and damage from swelling.
Surgeons clear away blood clots, dead tissue, and debris such as pieces of scalp and skull that could become infected. They repair the dura, the outer covering of the brain, so cerebrospinal fluid doesn't leak out, Loftus said.
Surgeons in Tucson removed a flap of skull to give Giffords' injured brain room to swell. The piece of skull typically would be kept in a freezer at minus-20 degrees Fahrenheit until the swelling subsides, usually six to eight weeks, said M. Sean Grady, chair and professor of neurosurgery at the Hospital of the University of Pennsylvania. Then surgeons fit it back into place. In the meantime, patients have a soft spot covered by scalp. People often wear a bicycle helmet for protection, he said.
His hospital treats 20 to 30 patients a year with gunshots to the head. About half live. They usually spend about a week in intensive care and a week to 10 days more on an acute-care floor, then go to a rehabilitation facility for one to two months.
Watanabe said therapists in Tucson probably were working to prevent problems in Giffords' right side by maintaining range of motion, and splinting her right hand and foot to keep them from curling awkwardly.
Doctors usually begin reducing sedation five to seven days after a gunshot. That's when they will get a better idea of how significant the damage is, Grady said.
Still, it will be months before the swelling is gone and pools of blood have been reabsorbed, the experts said.
Watanabe said brain damage usually extends well into tissue surrounding the bullet's path. There will be a highway of scar tissue through the left hemisphere, making it difficult for neurons on either side to communicate with one another.
Brain-injured patients like Giffords who have been on breathing machines often arrive at rehab unable to swallow, so that would be one of the first targets for therapists, said Todd Lewis, a neuropsychologist and brain-injury clinical specialist at Magee. "You don't just go from not eating to being able to eat steak and potatoes," he said.
Many also have bowel and bladder problems.
Some patients might be strong enough to start speech and physical therapy immediately. Others are so lethargic they need stimulants just to stay awake. Therapists start with sensory stimulation. Then it's on to very simple commands, such as "open your eyes."
Watanabe and Lewis said therapy begins by practicing simple movements and communication skills. If patients can't understand speech, therapists might combine pictures with words. At the same time, patients begin learning ways to circumvent their disabilities, such as doing more with the left hand if the right isn't working.
While patients with left-side damage might not be able to speak or understand speech, they can still think of things they want to do. That can be dangerous, Lewis said. Patients often are unaware of their impairments and might try to head for the bathroom with no idea that they might fall.
McMullin said he was aware of activity in his room while he was in a drug-induced coma. Later, he teased his mother, who had played one of his favorite Eric Clapton albums. He thought "I Shot the Sheriff" and "Knockin' on Heaven's Door" were amusing musical choices under the circumstances.
By the time he got to rehab, he felt fine - until he stood. Then he discovered that a brain injury coupled with complete immobility in a hospital can incapacitate even a young and fit man.
"The therapist and my brother, they dragged me down the hallway just to give me the feel of being able to walk," he said.
Later, he banged into people because he didn't realize he couldn't see. He had to learn how to organize his days and remember things.
His family's support was crucial to his recovery, he said. As a therapist, he said, he has seen that support drop off as patients spend more time in treatment. He urged Giffords' family to stick with it and "celebrate any kind of milestone that she makes."
As for Giffords, he said she needs to "be as strong as she can" during her therapy and accept that there will be good and bad days.
"Keep going strong, no matter how things in life turn out, because this new way of doing things . . . will get better," he said. "It will become a normal thing."