A MATTER OF MILLIMETERS: In addition to the size of the bullet, its path in the brain--or spinal cord--is key to determining a patient's rate and amount of recovery.
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A gunman's shooting distance and angle on a target can make all the difference between a victim's tenuous life, death or general recovery.
Before the crucial quick steps that aides and surgeons took to help save U.S. Rep. Gabrielle Giffords (D–Ariz.) soon after she was shot in the head on Saturday, the series of initial conditions that led to the bullet's trajectory through the brain—from the shooter's planning to his pacing—might have helped to spare her life and ultimately her functioning. And as past cases demonstrate, a shift of inches or a varied assault type can change everything for an individual patient, determining whether key brain regions are shattered or spared.
Although Giffords remains in critical condition, doctors say they are increasingly optimistic that she will survive. Details about the bullet's path have not been released per the family's request, but doctors have confirmed that it passed through the left hemisphere of her brain from back to front, fully exiting the head.
"This wasn't a little grazing wound," Peter Rhee, chief of the University of Arizona's University Medical Center (UMC) Division of Trauma, Critical Care and Emergency Surgery who has helped with Giffords's case, noted in a briefing on Sunday. "This was a devastating wound that traveled the entire length of the brain on the left side."
Motor skills and speech centers are located in the brain's left hemisphere in most people, and "depending on where it entered the brain in the back, it could affect some of her visual field," explains Marc Nuwer, a critical care expert and neurologist at the University of California, Los Angeles and member of the American Academy of Neurology.
"It's unclear whether she has damage to critical areas," Nuwer says, but because Gifford has been responding to commands, basic motor skills and "the understanding speech part seems to be working okay."
The bullet, which is reported to have come from a 9-millimeter Glock 19, is large compared with those that come from .22-caliber weapons. And bullet size is "relevant because very small caliber bullets, like a .22, cause much less damage than a larger bullet," says Nuwer, who has seen many people survive gunshot wounds to the head from these smaller bullets.
That the bullet cleared the skull helps to limit the opportunity for infection, but it also means that the congresswoman's brain bore less of the brunt of the bullet's full energetic load. Nuwer notes that if she had been hit on the head with a baseball that contained the same amount of force that the bullet contained, the brain would have likely sustained much more damage. But in Giffords's case, the energy was dispersed along the bullet's full track as well as being carried off away on the bullet's continued trajectory.
Unknown damage
Although researchers are still parsing out how different areas of the brain contribute to normal function, neuroscience has evolved a long way from the days of lobotomies to stave off seizures.
Surgeons can now often remove brain tumors and nearby damaged sections "and the patient will do marvelously after surgery," Nuwer says. But of course, Giffords's injury was nothing like a carefully mapped surgery.
The end result will depend largely on which regions are affected. "There are parts of the brain that do control specific functions," Nuwer says. "Other parts are a little more nebulous as to how they fit into the big picture." Some of these parts, he notes, "can be damaged and removed without causing noticeable impairment of function."
Surgeons working on the case at UMC noted in the Sunday briefing that they had found only minimal amounts of "devitalized" brain matter and had already removed it. Nevertheless, "as time goes on, the cavitation effects from the bullet itself" are likely going to continue to kill off brain cells, Rhee noted.
As doctors dial down anesthetics and remove the patient's ventilator tube, more will be apparent about Giffords's potential for recovery. However, "in neurosurgery, we talk about recovery on the orders of months to years," Michael Lamole, chief of neurosurgery at UMC, said on Sunday. "In fact, we don't even close the book on it until we're several years out."
But chances of survival even in the minutes and hours after a gunshot wound to the head are typically slight. "Overall, this is about as good as you're gonna get," Rhee said. "When you get shot in the head, and the bullet goes through your brain, the chances of you living are very small, and the chances of you waking up and following commands are actually much smaller than that."
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6 Comments
Add CommentMy brain injury stemmed from my heart stopping for 10 minutes during the suturing of a gash to my forehead under general anesthesia following a car accident, leaving me without ALL that we learn as infants - how to walk, speak, play tennis, remember, etc. I was able to get 95% of all that back by staggering, walking and jogging the 3.6 miles home from work 92 times (= 330+ miles) within a year of the cardiac arrest, and went on to become a professor at one of the premier design schools in the world, the Swiss campus of Pasadena's Art Center College of Design.
Reply | Report Abuse | Link to thisI am currently working on the design of a 100% sustainable world of the future, visible on my website at www.greenmillennium.eu In fact, it was the beginnings of these designs that occurred to me as I recovered, and pulled me forward, such was my desire to see the eternal components of our genes, in the form of our children's children's children's children's children's ...children benefit from this planet's first 100% sustainable and eternal infrastructure! So, the generation of altruistic goals can also provide a powerful incentive for many victims of similar situations to pull themselves into better, if not fully recovered, situations!!!
Please visit the website, and try it yourself!
This politician took a bullet for her constituents. Its really doubtful anyone else in Congress would be so dedicated to their work. This woman should be granted lifetime tenure in politics for her district as reward for her clearly evident loyalty to the voter. She will provide a most vivid object lesson to anyone in Congress as she walks the aisle to cast a vote bearing PROUDLY the medal of honor on her forehead for all to see. God Bless Gillford and God have mercy on America to have come to THIS...
Reply | Report Abuse | Link to thisThere is much that is new in our understanding of the brain; with this is added knowledge of how to have positive influence on brain self-regulation through neurofeedback procedures. This is a growing field of treatment.
Reply | Report Abuse | Link to thisSorry, Didonai, But nobody should get tenure for being a victim of such a tradgedy. In fact, we should impose term limits on all politicians. Its the carrer politicians who find what a greatg gig they have, that they do anything to stay there even if it means abandoning our representation for there own selfish interests... Serving our country as a career politician, is not what our fore-fathers (sp) had in mind.
Reply | Report Abuse | Link to thisNo. You need look no farther than California if you want to see what term limits does. Who wants to sign up for a job that they can only have for 8 years that costs millions to get? Answer? Idealists and people with no better options for the most part. Neither are good for politics.
Reply | Report Abuse | Link to thisIt takes 4-6 years to learn the job. So in California we get 2 years of real work out of our elected officials.
But the worst thing is that term limits make politicians more corrupt, more malleable to money influencing their vote. The reason is simple. They have nothing to lose! Since they know they are getting kicked out of office anyway, no matter how good a job they do, why should they care? So they do the predictable. They work to feather their nest after they are out of office, and cut more shady deals than ever.
It's not complicated, in fact this is all blindingly obvious. The "regular folks" who have the idea that term limits are good never put themselves in the shoes of the politicians they elect.
Ask yourself this, and answer honestly: If I were hired for a job, keeping it required prostituting myself to special interests in order to raise money to buy my way in, nobody really paid attention to how I did my job, and no matter how well I did my job, I would be fired at 4 years or at 8 years for sure, what would you do?
Really, truly, seriously, what would you do?
John, why did Californian's vote for term limits?
Reply | Report Abuse | Link to thisBecause the other option was not working either.
The problem isn't how long someone stays in office, it's a system that breed corruption and politicians representing special interest instead of those that elected them.
It's the system that needs to be changed.