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More than a headache: Surviving a hole in the head

By Dr. Billy Goldberg and Mark Leyner

We see a great deal of severe head trauma in the ER. Amazing survival stories, however, are few and far between.

For every headline-making tale of survival you hear about – a man is fine after being accidentally shot in the head with a nail gun or a boy completely recovers after a butter knife is lodged in his skull – most cases of head injury don't have happy endings.

The recent tragedy of welterweight Oscar Diaz is typical. The 25-year-old boxer is in a coma after collapsing in the ring on July 16. According to news reports, there was no sign that anything was wrong with Diaz until he grabbed his head and cried out just before the 11th round. Doctors think he will survive after surgery for bleeding on the brain, but whether he'll have a normal life is unclear.

When it comes to head trauma there's a weird phenomenon we often see in the ER — nothing turns out like you'd expect. Some people will suffer a simple fall and conk on the head and have horrendous injuries while others suffer brutal blows and come away unscathed.

Sure, there was the gang member shot four times in the face who didn't even lose a tooth. But on the other side is the innocent bystander hit by the bullet who dies instantly, or the grandma who trips going to the market to buy cat food and experiences life-threatening bleeding in her brain.

You can't talk about surviving a traumatic brain injury without mentioning the most celebrated head trauma patient of all time, Phineas P. Gage. In 1848, near Cavendish, Vt., an explosion blew a 3-foot iron rod through the head of Gage, a railway construction foreman. It entered his left cheekbone, passed through his skull, and exited out the top of his head.

Despite a few convulsions immediately following the accident, Gage remained alert and lucid, and recovered completely. There was one problem, though. Once an extremely polite, hard-working, compassionate man, Gage became a foul-mouthed, selfish, erratic, lying hooligan. Gage's accident helped provide science with insights into how the prefrontal cortex controls decision-making and personality. 

According to the Brain Injury Association of America, 1.4 million Americans will sustain a traumatic brain injury each year. Of those cases, 50,000 die and 235,000 are hospitalized. The Centers for Disease Control and Prevention reports that there are approximately 5.3 million U. S. citizens with a disabling brain injury. The costs of caring for the traumatized totaled $60 billion in 2000.

What determines whether someone walks away from a head injury and ends up on the TODAY show or ends up in a coma, or worse? There is a cynical ER saying that the key to is to be a drunk with a seizure disorder.

Seriously, it's all about which structures in the brain are injured and how severe the damage. Damage to the frontal lobes can cause changes in mood and personality or emotional instability. Injury to the area of the brain responsible for motor control can cause weakness. Temporal lobe damage can cause difficulty with language and trauma to the occipital lobe can cause blindness.

Another interesting result of head trauma can be anosmia, or the loss of smell. Approximately 5 percent of all head trauma patients exhibit total anosmia and around 30 percent of patients experience some decreased smell. Anosmia is usually due to shearing of the olfactory filaments at an area at the base of the skull.

Yamilet Leon, 7, is one of the lucky ones. The young girl was playing near a park in Sacramento, Calif., on July 3 when her brother heard gunshots. Yamilet complained of pain and doctors found the cause: a .22 caliber bullet just beneath the skin just above her temple. She's now recovering from surgery to remove the bullet.

Then again, how lucky are you if a bullet hits you in the head?