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Head

"We're in the midst of a vast paradigm, shift in the treatment of head injury," explains Sylvain Palmer, a neurosurgeon and chief of staff at Mission Hospital.
The numbers tell some of the story. In the three years since Mission Hospital established its program, results have improved dramatically. The number of patients with traumatic brain injuries who are able to function normally nearly tripled; death rates plummeted by almost two thirds; and the number of victims severely disabled or in a persistent vegetative state was reduced by half. Other U.S. hospitals with comparable brain-injury programs report similar results.
However, a survey done last year by the Brain Trauma Foundation revealed that only about one-third of the approximately 500 U.S. hospitals that treat traumatic brain injuries are using some of these techniques, and fewer than 1 in 5 use all of them.
"Trauma is the orphan child of medicine'- insurance reimbursement rates are low, so there's little financial incentive to change standard practices," said Ghajar.
As a result, cash-strapped hospitals are wary of spending money to set up new systems and buy the special monitors necessary to implement such programs. At Mission Hospital, for instance, treatment costs per brain-trauma patient jumped from $196,000 to  $300,000 "We have to eat the extra expense," says Palmer.

Medical professionals are also accustomed to treating brain injuries in a certain way and are

reluctant to make changes. "It's difficult to pull all the different teams together," says Mary Kay Bader, a neuroscience clinical nurse specialist at Mission Hospital. "Retraining required an enormous commitment from everyone, from the ambulance drivers ''to the trauma doctors, nurses and neurosurgeons."
Another part of the problem is that this. new approach flies in the face of traditional thinking about brain-injury treatment. Doctors have long known that the original injury isn't usually the source of all the trouble swelling afterward is the real culprit. When the soft brain tissue presses against the hard skull, it causes secondary injuries that often do much more damage than the initial insult. 'Worse yet, blood vessels constrict, depriving the brain of needed fuel and oxygen, so brain cells die.

Shrinking the. brain to relieve the pressure seemed to make the most sense. Trauma doctors used a variety of techniques to do this, such as giving patients diuretics to drain fluids and

steroids to reduce swelling. Subsequent research revealed, however, that many of these methods didn't help or were harmful because they reduced blood pressure so much that it stopped the blood flow. "It turned out we were starving the brain of essential nutrients, which was far more dangerous," says Ghajar.
To remedy this situation, a committee of the world's leading neurosurgeons did an extensive review of all the scientific literature on treating brain injuries to determine what methods consistently worked. Based on this, they devised treatment guidelines for brain injuries in 1996 that were adopted by the American Association of Neurological Surgeons and have become the gold standard for treating brain injuries. Yet most people who suffer traumatic brain injuries still leave the hospital with serious impairments because most hospitals don't follow the guidelines.

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Reporter Mary Powers contributed  to this story.